An Experiential Approach to Reliving with Complex Trauma. Dr Jo Billings Berkshire Traumatic Stress Service

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1 An Experiential Approach to Reliving with Complex Trauma Dr Jo Billings Berkshire Traumatic Stress Service

2 A Phase-Based Approach Stabilisation Processing trauma memories Reclaiming life

3 Overview What is the current evidence base and how to bridge gaps? How to deal with multiple traumas? Where to start? When to stop? How to manage high degree of distress, dissociation and avoidance? How to look after yourself?

4 Current evidence base

5 PTSD treatment evidence base Good evidence of efficacy for CBT and EMDR in the treatment of PTSD (Type I trauma) - Exposure elements key - CT can enhance treatment (guilt, shame) NICE guidelines recommend TF-CBT and EMDR 8-12 sessions for single incident trauma >12 sessions for where multiple traumatic events, traumatic bereavement, chronic disability, social problems and significant comorbid disorders

6 TF-CBT Treatment Models Prolonged exposure (Foa) Cognitive processing therapy (Resick) Cognitive therapy (Ehlers & Clark)

7 Prolonged Exposure 9+ sessions Often 2x week Psycho-education and treatment rationale Prolonged exposure mins In vivo exposure Some cognitive restructuring

8 Cognitive Processing Therapy 12 sessions 2x week Written exposure Explore themes/stuck points with CT Safety, trust, power/control, esteem, intimacy Re-write narrative

9 Cognitive Therapy 8-12 sessions Psycho-education and treatment rationale Reliving of key trauma memory Identifying hotspots Restructuring key meanings

10 Cognitive Model (Ehlers & Clarke, 2000) Nature of Trauma, Prior Experiences, Beliefs, Coping, State of individual Cognitive Processing during Trauma Nature of Trauma Memory Negative Appraisals of Trauma and/or its Sequelae Triggers Current Threat Intrusions Arousal Symptoms Strong Emotions Strategies Intended to Control Threat/Symptoms Avoidance/Safety Behaviours

11 Goals of Trauma Focused CBT 1. Elaborate memories 2. Identify and challenge negative appraisals 3. Reduce unhelpful maintenance strategies

12 Mind the Gap! Lack of psychological models of developmental and complex trauma Evidence base for treatment of complex trauma lags far behind that of adult trauma More gaps than guidance!

13 Gaps in the Research Established research on selected samples, with simple and clear research questions Only established models for single incident adult trauma Real life in trauma clinic more complicated! High rates of complexity, comorbidity, physical and situational problems Multiple traumas Childhood and adult trauma Pre-existing problematic schemas Systemic factors Clients heterogeneous with wide ranging problems, needs and preferences Culture/language differences Working with interpreters High levels of Risk Dissociation Self harm Limited time/resources

14 The nature of complex trauma Developmental Repeated, prolonged, anticipated Interpersonal in nature Often perpetrated by those supposed to protect you The closer the abusing relative to the victim the worse the prognosis Further damage caused by collusion, betrayal and denial of others (Waller) Complex emotional experience not just fear guilt, shame, anger, humiliation, disgust

15 The fallibility of memory Memory is reconstructive not reproductive A jigsaw puzzle rather than a DVD can put the pieces together in many different ways High probability of trauma memories being distorted and unreliable Nature of memory influenced by previous experiences of similar events Memory deficits normal

16 The fallibility of memory Childhood experiences encoded non-verbally Meanings of memories are developmentally congruent (Its my fault) Children have good procedural and semantic memory but poor autobiographical memory Poor autobiographical memory in adulthood Memory problems particularly likely in survivors of childhood trauma

17 Memory is changed by subsequent information because what we remember is an amalgam of what we witness and what we think BPS Working Party (1995) Conclusion: General memory is reliable, while memory for detail is not

18 Complex trauma, complex reactions, complex treatment! Integrative treatment models Evidence base as a starting point Adhere to key theory and principles Adaptation, creativity and flexibility Work with key meanings/affect via memory

19 Continua of Trauma Nature of Trauma Type I Trauma Not interpersonal Stable background Other protective factors Type II Trauma Interpersonal Unstable background Lack of protective factors Treatment Implications Specific focus Trauma focussed Classic CBT Brief General, multiple foci Schema focussed Phased approach Longer term From Rothschild (2000)

20 Where to start?

21 Memory Meaning

22 Reliving Restructuring

23 Getting an overview Overview of the client s history No surprises Cold reliving Positive factors and resilience

24 From narrative to reliving

25 Multiple trauma Multiple/overlapping traumas where to start?! Earliest Easiest Most recent Worst Most symptomatic Thematic

26 Traditional Re-living Protocol Systematic, repeated, prolonged exposure to a traumatic memory Graded approach with increasing detail if necessary Start at the beginning First person, present tense Finish in a safe place (fast forward if necessary)

27 Traditional Re-living Protocol Prompts What happens next What can you see, hear, smell, taste, feel What thoughts are going through your mind right now What do you feel in your body, where do you feel it What emotions do you feel, how strong Ratings SUDS Vividness Nowness

28 Getting the temperature right

29 Sensory cortices Parietal, Occipital and Temporal lobes: sensory processing Prefrontal Cortex Sensory inputs Thalamus Sensory gateway Hippocampus Stores memory of event Assessment of threat: tracks on-going reality Self-soothing Motor cortex Amygdala Emotional valence PERIPHERAL SYMPATHETIC & CORTISOL RESPONSES

30 Window of Tolerance Those who have suffered traumatic experiences can oscillate between hyper- and hypo- arousal Whilst in the window of tolerance a person can receive and integrate sensory information from the environment, while calling on the cortex, including the hippocampus, to assist with this assessment and integration Ogden, Minton & Pain, 2006

31 Elaborating Memories? Narratives Timelines Testimony Story boards Pictures Diagrams Photographs Maps Reliving Revisiting

32 Life story Trauma history Key trauma Key hotspot Key meaning

33 Changing Meanings

34 Cognitive Restructuring Socratic questioning Evidence for and against Advantages/disadvantages Cognitive continua Responsibility pie Cognitive biases (i.e. hindsight bias) Surveys Research Behavioural experiments Positive data log Return to site

35 Updating memories Verbally I know now that What is different now Imagery Visualising how wounds have healed Visualising family safe Physical movement Movements or actions incompatible with trauma memory Moving about if trapped

36 Intervention Points Complex Trauma Nature of Trauma, Prior Experiences, Beliefs, Coping, State of individual Cognitive Processing during Trauma Nature of Trauma Memory Negative Appraisals of Trauma and/or its Sequelae Triggers Current Threat Intrusions Arousal Symptoms Strong Emotions Strategies Intended to Control Threat/Symptoms Avoidance/Safety Behaviours

37 Intervention Points Complex Trauma Nature of Trauma, Prior Experiences, Beliefs, Coping, State of individual Cognitive Processing during Trauma Nature of Trauma Memory Negative Appraisals of Trauma and/or its Sequelae Triggers Current Threat Intrusions Arousal Symptoms Strong Emotions Strategies Intended to Control Threat/Symptoms Avoidance/Safety Behaviours

38 Emotional Bridge

39 Imagery Rescripting Integrated part of the reliving protocol (Ehlers et al., 2005) Aims to introduce new perspectives on what happened by experiencing new views and new emotions Works with representation in memory of what was experienced Changes relationship with memory

40 Imagery Rescripting Can provide corrective information Allow for expression of trauma inhibited responses May be more effective than exposure for emotions other than fear (Grunert et al., 2007) May be more effective intervention for guilt and anger (Arntz, 2007)

41 Imagery Rescripting Can vary from simple update (I know I did not die picture self with family now) through to complete imagery transformation (rescuing self, humiliating perpetrator) No limits to creativity! But aim to meet unmet needs at time of trauma (i.e. safety, compassion)

42 Bring distressing memory into awareness Imagine new memory in hotspot (re-rate belief) Identify hotspot and associated meaning (rate belief) Plan imagery to update belief Restructure belief

43 Bring distressing memory into awareness Imagine new memory in hotspot (re-rate belief) Identify hotspot and associated meaning (rate belief) Plan imagery to meet needs Identify unmet needs

44 Imagery Rescripting What would you have liked to do then that you couldn t? What would you like to feel in that moment? What would need to happen for you to feel like that? If you could go back in time and intervene what would you want to do? If someone could come back from the future to help you what would you like them to do?

45 Looking after yourself

Looking after yourself Control empathic attunement Peer and organisational support Regular supervision Use recordings to decentre Specific

46 Looking after yourself Control empathic attunement Peer and organisational support Regular supervision Use recordings to decentre Specific training Caseload balance Variety of work Good self care Optimism and hope Incorporate positive factors into formulation to avoid vicarious helplessness

PTSD Ehlers and Clark model

PTSD Ehlers and Clark model Problem-specific competences describe the knowledge and skills needed when applying CBT principles to specific conditions. They are not a stand-alone description of competences, and should be read as part